The “Post EHR” Era

Over the next few months, the majority of my time will be spent discussing topics such as care coordination, healthcare information exchange, care management, real time analytics, and population health. At BIDMC, we’ve already achieved 100% EHR adoption and 90% Meaningful Use attestation among our clinician community. Now that the foundation is laid, I believe our next body of work is to craft the technology and workflow solutions which will be hallmarks of the “post EHR” era.

In a “post EHR” era we need to go beyond simple data capture and reporting, we need care management that ensures patients with specific diseases follow standardized guidelines and protocols, escalating deviations to the care team. That team will include PCPs, specialists, home care, long term care, and family members. The goal of a Care Management Medical Record (CMMR) will be to provide a dashboard that overlays hospital and professional data with a higher level of management.

That data will be used in conjunction with rules that generate alerts and reminders to care managers and other members of the care team (plus the patient). The result is a Care Management Medical Record system based on a foundation of EHRs that provides much more than any one EHR.

My challenge in 2013-2014 will be to build and buy components that turn multiple EHRs into a CMMR at the community level.

This will require philanthropic funding, in kind contributions from selected vendor partners, and a willingness to take a risk on creating something that has never been operated at scale in the past.

BIDMC is a unique learning laboratory because 65% of its patients are already in global captivated risk arrangements.

If the CMMR can be created anywhere, it’s at BIDMC which strives to be agile and transparently share all its early experiences with the world.

I’m willing to lead the CMMR effort. In my discussions with many stakeholders over the next few months, I’m hoping to create a guiding coalition that will join me.

John Halamka, MD, is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.

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I am a bit surprised by the negative comments in response to a perfectly logical opinion about post EHR life.

For a care delivery organization to account for risk (an ACO), there is no other way but to have an effective care management. Traditional CM models have failed because intense manual touch makes them expensive and error prone. Smart analytics can resolve some of these issues. EHR is a medium to get there – a starting point. Just having an electronic record doesn’t help. Using it smartly is where the benefits are realized (obviously).

In fact, I’d go a step further. I think analytics on HIE is another piece of the puzzle – a step forward but not the end point.

EHR gives data. HIE aggregates it. Analytics interprets it. Then we will have to figure out the most efficient way to use it. That’s when we will start realizing value…!!

I agree, Akash. I do not mean to sound critical of anyone’s expertise, practice, etc., but we do not have enough science for what we currently do in healthcare. Other industries brought in more real world science (as opposed to controlled studies with carefully vetted patients that met criteria to enter the trial. AND not all the trials were published, we now have found out. So here’s a real world example. When working in the clinical world, I worked on a team responsible for nutrition support for traumatically injured patients. There was evidence for treating patients with isolated head injuries, or burns, or blunt trauma to the chest. What if you had a patient who threw kerosene on a fire and was burned from the resulting explosion, fell back and suffered brain injury, and also had bullets in his shirt pocket that went off and shot him twice through the chest? What evidence did you follow? Yes, you use your head to some degree, but as many of you can probably relate to, there was not perfect agreement among some very smart people! This is just an example, but if we had real data, and did not rely on our own biased anecdotal experience, about these complex situations, clinicians would use it to make better decisions. And for chronic conditions there’s even less real data because it’s difficult and expensive to get reliable data about what patients do outside an institutional setting. So most evidence is funded by pharmaceutical companies and device manufacturers with little data about what other conditions were involved. I would welcome opportunities to get real information about those complex patients that right now are not (in my opinion) getting the best care possible because we don’t yet know enough about what they’re doing.

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I C Farce, MD

Feb 13, 2013

Pompous description of care that has zero scientific basis. I am not aware of improve outcomes or reduced costs at BIDMC. The unexpected deaths, injuries and other adverse events caused by the EHR and CPOE are not being disclosed, and those that come to light, are blamed on the users.

For a foundation of care to be constructed of devices that have no safety or efficacy vetting is folly.

I’m thrilled the mainstream is finally recognizing that the EHR is only the tip of the HIT iceberg! What’s needed to accomplish the things John mentioned is paradigm shift supported by new (disruptive) innovations. This paradigm shift should be guided by a clear vision of the big picture.

I applaud your commitment to improving healthcare! Do you work with the end users of these systems? Specifically, the nurses? Do you seek out industrial engineers to help implement the system? I am a nurse and I am married to an industrial engineer. From having discussions about my work processes with him, I have discovered that many times nurses are working hard, but they are not working smart.

So basically you’re taking about building a hot shit academic CRM system and using it to manage patient records, test results, medical images, the little notes that doctors scribble down on the back of napkins that you have stored on electronic medical record systems, CPOE systems, remote data sources.

Feel free to correct me if I’m wrong, but I thought this was the point of the whole EMR exercise in the first place.

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